Wisconsin Birth Certificate Application

1 DEPARTMENT OF HEALTH SERVICES STATE OF Wisconsin . Division of Public Health Wis. Stat. F-05291 (Rev. 11/2016) Page 1 of 2. Wisconsin Birth Certificate Application . TYPE or PRINT. (for Mail or In-Person Requests). PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more than $10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. (1)]. CURRENT NAME - First Last MAIL TO NAME - First (if different) Last I. APPLICANT INFORMATION. YOUR STREET ADDRESS (CANNOT be a Box address) Apt. No MAIL TO ADDRESS (if different) Apt. No City State ZIP Code City State ZIP Code DAYTIME TELEPHONE NUMBER EMAIL ADDRESS.

2 ( ). TYPE OF CURRENT VALID PHOTO ID PHOTO ID NUMBER STATE OF ISSUANCE EXPIRATION DATE. (See item 4 on page 2.). Per Wis. Stat. (1), a CERTIFIED copy of a Birth Certificate is only available to those with a direct and tangible interest." (A E). PERSON NAMED ON THE Certificate . CHECK ONE box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the Birth Certificate . II. APPLICANT'S RELATIONSHIP TO. A. I am the PERSON NAMED on the Birth Certificate . B. I am a member of the immediate family of the person named on the Birth Certificate . Parent (My name is on the Birth Certificate and my parental rights have not been terminated.). Brother / Sister Current Spouse Child Maternal Grandparent Paternal Grandparent Current Domestic Partner (registered in the Wis.)

3 Vital Records System). C. I am the legal custodian or guardian of the person named on the Birth Certificate . D. I am a representative authorized by any person in category A, B or C, including an attorney. Specify the person you represent: _____. E. I can demonstrate the Birth Certificate is necessary for the determination or protection of a personal or property right. Specify your interest: _____. F. None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.). NOTE: Grandchildren, stepparents, stepchildren and stepbrothers / stepsisters may only obtain certified copies as categories C-E. PURPOSE FOR WHICH Certificate IS REQUESTED: First Copy Fee.

4 $ III. FEES. Each additional copy of the same record, issued at the same time as the first copy $ _____ X $ _____. Number of additional copies FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED. $ TOTAL _____. Submit your Application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309. Be sure to include: completed form, acceptable identification, payment, self-addressed, stamped, business-size envelope, and any additional proof or authorization required Make check or money order payable to: STATE OF WIS. VITAL RECORDS. Birth NAME - First Middle Last Name as it appears on the Birth Certificate IV. Birth RECORD. INFORMATION.

5 SEX BIRTHDATE (MM/DD/YYYY) PLACE OF Birth - County PLACE OF Birth City, Village, or Township Male Female PARENT'S Birth NAME First Middle Last PARENT'S Birth NAME First Middle Last I hereby attest that the information provided on this Application is correct to the best of my knowledge and belief and that I am entitled to copies of the requested Birth Certificate in accordance to the categories listed above. SIGNATURE (Applicant) Date Signed (MM/DD/YYYY).. Important: Signature and payment are required for processing. Clear / Reset Form Wisconsin Birth Certificate Application Page 2 of 2. F-05291 (Rev. 11/2016). 1. What is the difference between a certified and an uncertified copy of a Birth Certificate ?

6 A CERTIFIED COPY: Is printed on security paper, has a raised seal, and shows the signature of the State Registrar or Local Registrar. Can be used for legal purposes. Can only be obtained with a direct and tangible interest as defined in Wis. Stat. (1). AN UNCERTIFIED COPY: Is printed on plain paper and marked uncertified.. Is for information purposes only and cannot be used for identity or legal purposes. Contains the same information as a certified copy. 2. Limitations on access to certain Birth certificates According to Wis. Stat. ch. 69, uncertified copies of the following types of Birth certificates may not be obtained by anyone: A child born to unmarried parents and paternity has not been established.

7 A child born to unmarried parents and paternity was established by court order. 3. How long will it take to process my request? APPLYING IN PERSON. Requests for certified copies of Birth certificates are usually completed within 2 business hours of Application , if the Birth Certificate is on file. Requests for uncertified copies of Birth certificates are not completed on the same schedule as requests for certified copies. In- person requests for uncertified copies may take up to 1 month to complete. APPLYING BY MAIL. Requests for certified copies of Birth certificates may take up to 2 weeks plus mail time to complete. Requests for uncertified copies of Birth certificates are not completed on the same schedule as certified copies.

8 Mail requests for uncertified copies may take up to 1 month plus mail time. 4. What identification is required when applying for a Birth Certificate ? Requests for certified copies require proof of identification. Applicant's original ID is required for in-person applications. A photocopy of the applicant's ID is required for mail applications. At least one form of ID must show your name and address. Expired cards or documents will not be accepted. Examples of acceptable forms of identification include: One of these: OR Two of these: State issued driver's license or ID card Bank/Earnings statement US Government issued photo ID Current, dated, signed lease US or Foreign passport Health insurance card Tribal or Military ID card Utility bill or traffic ticket Vehicle registration/title If you have questions regarding this form, please call 608-266-1373.

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